Patient Registration Form

For Office Use Only

Account :

Doctor :

Office Location :

FAIR LAWN
MAHWAH
HOBOKEN
CLIFTON

Check In :

Paperwork Completed :

Have you been treated by Dr. Levitsky, Dr. Holden, Dr. Snyder, Dr. Bernstein, Dr. Shamash, Dr. Brian Van Grouw, William Thomson, PA-C, Bryan Sheldon PA-C, Kimberly VanPelt PA-C, Long Bui-Le PA-C or Jeffrey Lee PA-C in a local hospital?
Yes
No
Have you ever been seen in the Fair Lawn Office
Mahwah Office
Hoboken Office
Clifton Office
Midland Park Office
When were you treated by the medical provider?

All fields in GREEN are required

Last Name :

First Name :

Marital Status :

Single Married SeparatedDivorced Widowed

Street Address :

City :

State:

Zip Code :

Home Phone :

Business Phone :

Cell Phone :

Pharmacy Phone :

E-mail address :

Social Security Number :

Date of Birth :

Age :

Sex :
Male
Female

Name of Employer/School/Or Name of Parents Employer :

Occupation :

Street Address :

City :

State :

Zip Code :

In Case Of Emergency, Contact :

Phone :

Relationship :

Street Address :

City :

State:

Zip Code :

Please Explain Cause of Injury :

Pharmacy Name :

Pharmacy Address :

Pharmacy Phone:

Pharmacy Fax :

(MUST BE COMPLETED FOR PRESCRIPTION ISSUE/RENEWALS)

RACE

LANGUAGES

ETHNICITY

ASIAN
BLACK
HISPANIC
PATIENT REFUSE
WHITE

ENGLISH
FRENCH
GERMAN
OTHER
POLISH

LATINO
NOT LATINO
PATIENT REFUSE

IS THE INJURY RELATED TO:(IF APPLICABLE, PLEASE CHECK ONE)

Motor Vehicle Accident
Work
Sports

Name of the Motor Vehicle Or Worker Compensation Carrier :

Address of Carrier :

Telephone Number :

Claim Number :

Adjusters Name :

How did you hear about GARDEN STATE ORTHOPAEDIC ASSOCIATES, P.A.?
MD REFERAL
FRIEND
OTHER

Primary Care or Internist Name :

Phone Number :

Street Address :

City :

State :

Name of Person To Bill For Todays Visit :

Home Phone :

Street Address :

City :

State:

Zip Code :

Relation To Patient :

Date of Birth :

Social Security Number :

Name of the Employer :

Street Address Of Employer :

City :

State:

Zip Code :

Business Phone :

Primary Insurance Company To Bill :

Policy Holders Address :

Policy Holders Employers Name :

Relationship :

Policy Holders Employers Address :

Insurance ID Number :

Policy Holders Name :

Policy Holders DOB :

Sex :

Local/Group Number :

Policy Holders Social Security Number :

Policy Holders Work Number :

Name of Secondary Insurance To Bill :

Policy Holders Address :

Policy Holders Employers Name :

Policy Holders Employers Address :

Insurance ID Number :

Policy Holders Insured Name :

Policy Holders DOB :

Sex :

Local/Group Number :

Policy Holders Social Security Number :

Policy Holders Work Number :

Account #:

Height:

Weight:

Are you allergic to any of the following:

Yes

Yes

Adhesive Tape

Metal

Iodine

Contrast Dye

Latex

Auto Immune

Eggs

NONE

Do you have any drug allergies? (please list/explain)

None

Mark if you have been diagnosed with any of the following:

Yes

Yes

Bone Cancer

Duodenal Ulcer

Breast Cancer

Hepatitis, unspec type

Colon Cancer

Hepatitis, spec type

Lung Cancer

AIDS/HIV

Prostate Cancer

Kidney Disease

Other Cancer

Arthritis, unspec type

Arthritis, osteo

(Please specify)

Arthritis, rheumatoid

Elevated Cholesterol

Osteoporosis

Heart Attack

Gout

Heart Disease

Anxiety

Hypertension

Depression

Stroke

Thyroid Disease

Cataracts

Anorexia/Bulimia

Glaucoma

Diabetes

Asthma

Obesity

Tuberculosis

NONE

Mark family members who have been diagnosed with any of the
following:

I acknowledge full responsibility for the payment of services rendered to me and agree to pay for such services in full, regardless of insurance or third party involvement, unless otherwise prohibited by law • I have been informed as to my innetwork or out-of-network status prior to my visit • I authorize the practice to release to my insurance company or any of my third party payors any information needed to determine my insurance coverage • I authorize you to file claims with all insurance and third party carriers and further authorize and direct my insurance benefits to be paid directly to Garden State Orthopaedic Associates, P.A. 28-04 Broadway, Fair Lawn, NJ 07410 Tax ID #222814819

Please note that our office makes supplies available for your convenience. All medical supplies must be paid for at the time of your visit.

Patients are responsible to pay a 1% per month finance charge on all unpaid balances which exceed 30 days.

I verify the accuracy of the above information and authorize release of information as provided.